Immunisation and Anaesthesia

  • Introduction

    Anaesthetic and surgical staff are often presented with children who have recently been immunised, for either emergency or elective surgery. Although there is no direct evidence of any major interaction between immunisation and commonly used anaesthetic agents and techniques in children, it is possible that the anaesthesia or surgery may affect the immune response of the vaccine. It is also possible that the systemic effects from immunisation, such as fever, may confuse the clinical management of the patient during the post-operative period. It is therefore important that an immunisation history is undertaken prior to surgery. 


    The aims of this guideline are:

    • To inform medical and nursing staff about practice regarding the timing and side effects of immunisation with respect to general anaesthesia and surgery.
    • To outline eligibility criteria where a patient could receive vaccination whilst under general anaesthesia.
    • To outline the steps of getting a patient vaccinated under general anaesthesia if indicated.
    • To indicate if scheduled immunisation should be delayed if a child has had either elective or emergency surgery.

    Definition of terms

    • AIR – Australian Immunisation Register, a national register where vaccinations are recorded
    • Anaesthesia – insensitivity to pain, especially as artificially induced by the administration of gases or the injection of drugs before surgical operations. 
    • EMR – Electronic Medical Record
    • Immunisation – the process of inducing immunity to an infectious agent by administering a vaccine.
    • Inactivated vaccine -- the viruses or bacteria in vaccines are completely inactivated (or killed) with a chemical so that they cannot reproduce themselves or cause disease but are still recognised by the body's immune system to achieve immunity.
    • Live attenuated vaccine -- the live viruses used in vaccines are weakened (or attenuated) and they replicate themselves to cause the immune system to produce protective antibodies.
    • Needle phobia – severe fear of medical needle procedure and/or recent prior failure to vaccinate due to severe fear or distress of the procedure.
    • NIP – National Immunisation Program
    • Vaccination – the administration of a vaccine; if vaccination is successful, it results in immunity.

    Eligibility for immunisation under anaesthetic

    There may be circumstances where vaccination under general anaesthesia may be the best option for the patient.  Specifically:

    • Patients with developmental or behavioural disorders (such as autism spectrum disorder);
    • Children and adolescents with extreme anxiety or needle phobia;
    • Patients requiring four (4) or more injections.


    Preoperative assessment

    • Pre-assessment of patients who are going for surgery to be done by the Nursing Care Coordinator at least one day before the surgery to determine if the patient requires vaccination under general anaesthesia.
    • If yes, inform the perioperative team and the anaesthetist and arrange with the RCH Immunisation Centre.

    Admission assessment

    On admission the nurse should check the patient’s immunisation status with a parent or care giver.

    The nurse should document if a patient is up to date with vaccination as well as if a patient has received a live attenuated parenteral vaccine in the last 10 days or an inactivated vaccine within 48 hours of the planned surgery.  

    If the patient has received a vaccine, the perioperative team should be advised.

    Immunisation under anaesthetic

    • If upon pre-operative assessment, the patient meets the eligibility for immunisation under anaesthetic, then discuss with the perioperative staff a plan for vaccination. 
    • For patients who are unable to receive an immunisation under anaesthetic, vaccines can be administered upon discharge at the RCH Immunisation Drop-in Centre, at a follow-up outpatient appointment at RCH, or via the patient’s General Practitioner.


    Pre-operative / Intra-operative

    As both anaesthesia and surgery may impair the immune system, there is the theoretical risk of altered response to vaccines if surgery is performed in close proximity to vaccine administration.   Also, vaccine side effects can be similar to postoperative events, possibly confusing the signs of surgical complications.  There is no absolute contraindication to opportunistic vaccination during general anaesthesia, but plans for opportunistic vaccination should be made on a case-by-case basis and take into consideration the patient’s medical history and the procedure itself (see eligibility criteria above).  Immunisation could be given when the child has recovered, before discharge.  

    In situations where intra-operative vaccination is required, this is to be negotiated with the Royal Children’s Hospital (RCH) Immunisation Centre nursing staff and the perioperative staff prior to the patient entering the Operating Suite. This can be via the Nurse Coordinator.  Steps:

    • Inform the nursing staff of RCH Immunisation Centre at least one day before the patient’s surgery or procedure under general anaesthesia (or on Friday if the surgery is on the following Monday);
    • Consent for vaccination under general anaesthesia needs to be documented on the Consent Form;
    • Nursing/Pharmacy staff of RCH Immunisation Centre need to go through the pre-vaccination screening checklist and discuss the vaccine side effects with the parent/carer prior to vaccination, as well as obtain and document in the EMR parent/guardian consent;
    • Anaesthetist or other perioperative staff member contacts the RCH immunisation Centre ten (10) minutes prior to taking the patient into the Anaesthetic Induction Room;
    • Nursing staff of RCH Immunisation Centre administers vaccinations according to the Clinical Practice Guideline on Immunisation of Inpatients once the patient is anaesthetised.
    • If the RCH Immunisation service staff are unable to administer the vaccine(s) due to time constraints, then the anaesthetist can administer if the vaccine is prescribed in the EMR.  Theatre staff will need to obtain the required vaccine(s) from RCH pharmacy.

    Please note:

    • Recent immunisation does not impact upon the outcome of surgery.
    • Possible side effects such as mild fever, irritability or sleepiness may occur up to 48 hours following immunisation with inactivated vaccines, or high fever around 7 to 10 days following immunisation with live attenuated vaccines. This is more likely to be a real problem following major surgical procedures, as fever and malaise may cause confusion in the post-operative period.
    • Record date of recent vaccination in the Nursing assessment and inform surgical and anaesthetic staff so that this can be taken into account when managing the patient post-operatively.

    Documentation of vaccination:

    All vaccines administered to patients should be documented in the patient’s EMR and the individual child health record.  Once documented in the EMR, an inbasket message is automatically sent to the Immunisation staff for recording on the Australian Immunisation Register (AIR).


    • There is no contraindication to immunisation immediately after surgery, once the child is well and has recovered from the procedure.
    • Delaying immunisation increases the risk of infection in the affected child, and has been shown to result in non-completion of the immunisation schedule in some children. The importance of completing the immunisation schedule both for the child and the community outweighs any concerns about the impact of immunisation upon surgery and the impact of surgery upon immunisation.


    • Where possible people having a planned splenectomy should ideally receive all additional vaccines at least 2 weeks prior to surgery. This is to ensure optimal protection prior to spleen removal.
    • Those who undergo an unplanned or emergency splenectomy should defer vaccines for at least 7 days following surgery to allow time for recovery.

    As per:

    Blood products during surgery

    A person who receives any blood products during surgery will need to delay some vaccinations. As per:


    RCH Immunisation Drop-in Centre opens from 9:00am - 4:30pm Monday to Friday (except public holidays). Phone: 93454899 

    Inactivated vaccines  

    Diphtheria-tetanus-acellular pertussis (whooping cough)

    Haemophilus influenzae type b

    Hepatitis A

    Hepatitis B

    Human papillomavirus 


    Inactivated poliomyelitis


    Meningococcal ACWY

    Meningococcal B

    Meningococcal C

    Pneumococcal conjugate

    Pneumococcal polysaccharide

    Live attenuated parenteral vaccines

    Measles-mumps-rubella (MMR) 

    Measles-mumps-rubella-varicella (MMRV) 

    Varicella (chickenpox)



    Please remember to read the disclaimer

    The development of this clinical guideline was coordinated by Sonja Elia, Nurse Practitioner, Immunisation . Approved by the Clinical Effectiveness Committee. Updated December 2023.

    Evidence Table 


    Source of Evidence 

    Key findings and considerations
     Association of Paediatric Anaesthetists of Great Britain and Ireland (2010).  Immunisation Guideline: the timing of vaccination with respect to anaesthesia and surgery.  Retrieved from Expert opinion
    1. Surgery following immunisation with inactivated vaccines
    2. Surgery following immunisation with live attenuated vaccines
    3. Vaccination after surgery
    4. Advice for pre-assessment

      Australian Government Department of Health (2020).  The Australian Immunisation Handbook. Retrieved from

      Expert opinion Vaccination before or after anaesthesia/surgery

      Bertolizio, G., Astuto, M., and Ingelmo, P. (2017).  The implications of Immunization in the daily practice of pediatric anesthesia.  Current Opinion in Anesthesiology, 30(3), 368-75. doi: 10.1097/ACO.0000000000000462

      Expert opinion
      1. Postpone an elective procedure that requires anesthesia rather than alternating the vaccination schedule
      2. Postpone anesthesia and surgery 1 week after vaccination with inactivated vaccines
      3. Postpone anesthesia and surgery to 3 weeks after vaccination with live attenuated vaccine
        Crowcroft, N.S., & Elliman, D. (2007). Vaccination and anesthesia: the precautionary principle is to vaccinate. Pediatric Anesthesia, 17(12), 1216-1218 Expert opinion

        Impact of delaying surgery or delaying vaccination is likely to do more harm than good and the safest outcome is when in doubt, vaccinate

        Currie, J. (2006). Vaccination: is it a real problem for anesthesia and surgery? Pediatric Anesthesia, 16(5), 501-503
        Expert opinion 

        Inactivated vaccines – delay anaesthesia for 7 days

        Live vaccines – delay anaesthesia for 3 weeks  

        Nafiu, O. O., & Lewis, I. (2007). Vaccination and anesthesia: more questions than answers. Pediatric Anesthesia, 17(12), 1215. Expert opinion Editorial comment that delaying anaesthesia after vaccinations is too strong recommendation based on findings in research  


        Lonsdale, H., & Sivaprakasam, J. (2014, June). Immunisation and general anaesthesia – audit of practice in a specialist paediatric hospital. Paper presented at the AAGBI GAT Annual Scientific Meeting, Newcastle upon Tyne, UK. Abstract retrieved from

        Expert opinion

        Highlighted lack of compliance with national guidelines and lack of knowledge of local procedures (which were out-dated)

        Lin C, Vazquez-Colon C, Geng-Ramos G and Challa C (2021).  Implications of anesthesia and vaccination.  Pediatric anesthesia, 31:531-538.

        Expert opinion Opinion piece and review of literature and recommends that vaccination during surgery should be made on an individual bases involving MDT discussions.

        Pandey, R., Garg, R., Darlong, V., & Punj, J. (2008). Vaccination and urgent surgery in children: anesthetic concerns. ACTA Anaesthesiologica Taiwanica, 46(4), 199-200. doi: 10.1016/S1875-4597(09)60011-4 Expert opinion Letter to the editor about a case study , recommending delaying surgery, for 2 days with inactivated vaccines and 21 days for live vaccines to prevent confusion between possible vaccine related adverse events and postoperative complications


        Popa, A., Malos, A., & Cernea, D. (2009). Recently immunization and anesthesia of the children. Current Health Sciences Journal 35(3), 201-204. Retrieved from

        Expert opinion

        Opinion piece and review of the literature recommending that elective surgery and anaesthesia should be postponed for one week after inactive vaccination and 3 weeks after live attenuated vaccination in children

         Rao S, Morrissey T, Ziniel SI, Mandler T, Yaster M and Strupp KM. (2022).  Influenza Vaccination in Perioperative Settings: A Teachable Moment.  Anesthesiology, 137:745-747. Expert opinion Letter to the editor about a standardized process to actively offer influenza vaccination to all patients undergoing elective general anesthesia.  Influenza vaccination rates improved by 11%.

        Short, J. A., van der Walt, J. H., & Zoanetti, D. C. (2006). Immunization and anesthesia – an international survey. Pediatric Anesthesia, 16(5), 514-522. doi: 10.1111/j.1460-9592.2006.01897.x

        Expert opinion  Recommend elective surgery and anaesthesia be postponed for 1 week after inactive vaccination and 3 weeks after live vaccination

        Siebert, J. N., Posfay-Barbe, K. M., Habre, W., & Siegrist, C. A. (2007). Influence of anesthesia on immune responses and its effect on vaccination in children: review of evidence. Pediatric Anesthesia, 17(5), 410-420. doi: 10.1111/j1460-9592.2006.02120.x

         Systematic review

        Recommend not to postpone surgery in recently vaccinated children, although a delay may be useful to avoid misinterpreting post-operative complications